Dinah, ClinkShrink, & Roy produce Shrink Rap: a blog by Psychiatrists for Psychiatrists, interested bystanders are also welcome. A place to talk; no one has to listen.

Thursday, February 02, 2012

The Violent Patient

On the New York Time's Well blog recently, nurse Theresa Brown wrote a piece entitled "Feeling Strain When Violent Patients Need Care," in which she talked about caring for a very threatening, potentially dangerous patient suffering from cancer. This patient, a large 300 pound man, had a reputation for causing havoc in the hospital. He had been banned from one ward for tearing a light fixture off the wall and fighting with hospital security. He had "slugged" a family member at the nursing station and threatened to kill a nurse. In spite of all this, he apparently was not in custody at the time that Ms. Brown was caring for him, which meant that he was not a prisoner in shackles and there was no dedicated law enforcement professional watching over the situation. Understandably, Ms. Brown was afraid.

What some people might not appreciate or been aware of, was that she was also embarrassed about being afraid. Working in the health care field, and in nursing in particular, meant that one could be exposed to volatile situations at any time. Being a professional meant being able to stay calm and poised enough to manage these situations, and this is where the author of this piece felt lacking. She felt she should have been tougher, more unflappable, or somehow invincible to this very concerning patient's intimidating demeanor. Ultimately she was replaced on the case by a male nurse. We never find out what happened to the patient, whether he actually did commit acts of violence during that admission, or whether he calmed down with the male nurse and cooperated with the care he needed. We also don't come to any resolution about what a health care professional should do in a situation like this. This is not a question the narrative was meant to answer, apparently.

As always in story like this, the most interesting part to me were the comments that followed. Over the next two days nearly one hundred people wrote in, mostly nurses and doctors and other health care professionals, to talk about the multiple incidents in which they were bitten, scratched, spat upon, cursed, hit and kicked in the emergency room, on the psychiatric unit, and in the intensive care unit. Half way through the comments I found myself wondering what the incidence of post-traumatic stress disorder must be among health care professionals after a few years of routine work. (I don't know the answer to that question.)

I was also impressed by the range of thoughtfulness that some commenters brought to the situation. Some quickly speculated that the patient might have been a veteran or someone equally traumatized, who would naturally have responded with aggression when startled awake in the middle of the night by a stranger. Others speculated that he might have been having an unexpected reaction to a medication, or been in the midst of a delirium. Some suggested that a CT scan should have been done to make sure his impulsivity and temper weren't due to a malignant brain metastasis. Clearly, these health care professional readers were setting aside their own personal experiences to consider the cause of the patient's emotional reaction and behavior. This was heartening to me.

Other comments were less sympathetic, implying that hospitals should be more liberal in their use of physical and chemical restraints and that assaultive and threatening patients should be prosecuted consistently.

I felt rather fortunate after reading this piece. I've worked with patients known for this kind of violence, but I've been comfortable doing so knowing that safety and security were a necessary and essential condition to providing treatment. I've always felt safer in most correctional facilities I've worked in than in some more traditional clinical settings. Even so, I rarely have had to deal with patients who were so angry or potentially dangerous that I wasn't sure I could treat them even in the correctional setting. That's not good because in most cases there is no one else to turn the patient's care over to when you're the only shrink in the building. This is how I've managed to handle it:

If the patient starts the appointment calmly but escalates during the interview, the first thing I do is slow down. I want time to listen, to think, to make sure the patient knows that I'm hearing him and am concerned about what he's saying. This also helps me listen better. I set my pen down and stop taking notes. I look at the patient. I make sure he knows he has my full attention. If he allows me, I will ask questions to get more information or to clarify something he has said. I repeat what he's told me, and ask him if I am understanding him. If and when he says 'yes', things chill out immediately and we negotiate a treatment plan.

If this doesn't help, or if I start to feel I can't listen safely, I tell the patient I feel uncomfortable or worried. It's not waving a red flag in front of a bull to admit that you're scared. You'd be surprised how many temperamental men (I only treat male prisoners) have no awareness whatsoever that they are talking way too loud or gesturing too broadly or behaving in a way that attracts attention. The nearest correctional officer usually notices first. If I see an officer glancing in to check on me that gives me a nice opportunity to point out to the patient that his behavior is arousing the concern of custody. That always works.

I'm surprised how often an angry inmate will suddenly pull himself together and calm down once you tell him you're scared. Some of them are quick to apologize, or emphasize that---in spite of what they might have done in the past---they have never laid hands on a woman.

Lastly, I know when to recognize when I need to take a break. If I find myself wanting to cut the patient off or getting annoyed---too annoyed to listen---I know it's time to call it a day and try again another time. These are the times when mistakes get made. I can ask the patient if we can take a break and come back to the discussion later in the clinic session, or on another day. I explain that things have gotten heated and I really want to make sure I'm taking the time to think about his care.

If none of this works, I still keep trying. I will make sure I have any necessary security in place, and explain to the patient why it's needed. If someone is available, I may ask another health care professional to sit in the room with me. And make sure an officer is outside the door. In extreme cases, it might be necessary to put the person in handcuffs and a waist chain for the appointment.

Hospitals aren't used to doing any of this, or can't. But when 15% of all US nonfatal on the job injuries take place in health care settings, through patient assaults on staff, it's time to take de-escalation training seriously.

I have once had the opportunity to handle a woman who was in an extreme state of agitation and never for once was I scared. She could have done anything and she could have easily hurt me, but then that was not really what I was concerned about for I wanted to understand the cause behind her behavior and I stayed all the while trying to communicate with her. This post was interesting and it gave me a new kind of understanding about handling patients in a kind of setting where there is every chance for the therapist to get hurt. I guess it truly tests the presence of mind of the practitioner and enables them to either put to use some of these tactics or to come about instantaneously with something of their own.

Psych Sci: You're right, it does test presence of mind. Hopefully, hospitals and training programs won't leave the employee/student to come up with something on their own but will provide an inservice or ongoing supervision about what to do when this stuff happens. I'm glad the situation worked out for you. Did you have someone who could review what happened with you? This can be helpful after the fact, to identify what triggers patients so you can prevent future incidents.

I have twice had to deal with violent patients as an ortho resident,almost 20 years ago. The first was an elderly man with severe dementia and a hip fracture. I was called to emerg to admit him. He was incoherent and took swings at me if I stepped too close. I had no idea of how to handle him, emerg staff had passed him off to me and were on to more important things. I think that my history was confined to the nursing home notes, and physical to broken hip, moving all limbs, heart and lungs present. The other was also a gentleman with a broken hip, but this time drunk as a skunk, 40ish, and also with a boxer's fracture. It was 3AM, and I had to admit him and reduce and cast his boxer's fracture. He alternated between trying to slug me and grope me. Again, handed off by emerg staff, no help. I got the boxer's fracture dealt with, and chose to wait until 7 to alert my staff. Big mistake, I was reamed out for not having called him right away as the hip fracture was a surgical emergency. I was further rewarded by having to present a rounds on classification and management of hip fractures. Today, nobody gets woken up at 3AM for a hip fracture. I suppose that I was lucky that both of these patients had the restraint of a hip fracture, and I learned to be quick on my feet. We never received any training on how to deal with violent patients. Now I'm mostly in the OR and we do get some patients who wake up disoriented and swinging, but that is a temporary condition. I am grateful to not routinely have to deal with violent patients!

I just found this Cochrane review addressing evidence for the use of behavioral management strategies for inpatient violence (eg. not physical or chemical restraints). They searched the literature for studies involving the use of close observation, verbal de-escalation, behavior contracts and locked wards. In spite of 4800 papers published about this since 1995, none were controlled trials. Wow, so essentially there is no evidence that non-pharmacologic interventions are effective (or more effective) than pharmacologic management.

I take offense to your saying those who commented about taking action/setting appropriate boundaries with violent people were "less sympathetic".

I have real concerns there are clinicians out there amongst us who want to make antisocial and sociopathic issues psychiatric matters of alleged effective interventions.

Some people are just bad, and that is why we have jails and graveyards. Maybe it is time to reexamine overtolerance as much as be wary of intolerance. And why it is often the people who tell us to engage with dangerous people are themselves the closest to the door to flee first?!

@Psychology Scientist: sometimes being scared is the best and most appropriate response. Fear may alert us to a situation that is, in fact, dangerous and might spin out of control.

At times patients are not aware of how frightening they actually are, and letting them know that (as Clink said) may help them remain calm.

Over the years there have been a few times when a patient has been quite threatening. One large and powerful man once picked up the lamp on the table next to him and motioned to throw it at me (yes, the cord would have stopped it - cold comfort). It was a lamp I particularly valued, too, so I had multiple emotions at that point.

Being able to judge reasonably accurately when one is safe is an important skill. It can be threatening to the patient to have too few constraints on his bahavior, and may lead to unnecessary violence.

thanks for posting about this-- it resonated with my experiences. i worked at a children's home for over two years while i was getting my psychology degree. i loved my kids-- from five to fourteen years old; most had been severely traumatized, and acted out in some horrible ways. on multiple occasions, despite our training and experience, our de-escalation methods were unsuccessful, and i (with colleagues) had to restrain kids to keep them, staff, or other kids safe. some of the older kids were adult-sized, but they were all still children, and that made it all a bit easier, i think. still, the act of restraining a child that has been raped/assaulted/harmed so grievously was difficult, emotionally and physically. it's important to prevent these types of incidents, and important to handle them as calmly and gently as possible to prevent further trauma. most helpful to me, to prevent personal trauma and pain? talking it all out after the incident with a co-worker... it kept any difficulties with this stressful work from building up. and laughing at the absurdity, sometimes helped too.

Rob, isn't Special K just another name for Ketamine?Anon Clin: I think that Clink was merely offering a summary of the comments she read, not stating that she sympathized more with some than with others. We do have jails for people who commit bad acts. As for graveyards, I believe that the residents represent a cross section of the population. They aren't just for bad people. I wouldn't recommend that go killing all the bad people anyway, if that is what you were suggesting. And where do you draw the line between good and bad? Life is more complicated than that.

Anonymous Clinician: Anonymous Human already posted what I would have said. My comment was a descriptive statement of fact, not a judgment. I don't think the decision to prosecute violent patients is a clearcut one, with both clinician and patient factors to consider.

Interpretation is individual specific. I reread your post and still feel it has a judgmental tone. My issue, but, you did not address my concern of lumping too much antisocial matters into general mental health care treatment arenas.

Don't see many forensic colleagues freely offering to treat those they so quickly label impaired in correctional settings. A tad hypocritical, hmm?

Rob, sorry for the confusion. I had to post then put back in drafts so that I had a permalink to use in the CPN post. Once the CPN post on Ketamine went up, then I was able to put up the companion post on Shrink Rap.

Anonymous clinician: I need some clarification on your statement 'lumping antisocial matters into mental health treatment.' I didn't respond because I didn't understand your meaning. There's more than one way you could mean that: 1. giving a diagnosis to lawbreaking behavior or 2. supporting a legal finding of insanity through expert opinion. Or maybe you mean something completely different (with apologies to Monty Python).

Regarding willingness of forensic psychiatrists to provide treatment (regardless of setting), I'd say part of the problem is that there aren't very many of us to begin with. With about 1700 in the country, compared to the number of forensic hospitals and correctional facilities, yes you won't see many forensic psychiatrists providing services. Often these are provided by non-forensically trained docs or locum tenens people. Or positions are left unfilled.

I can tell you based on my N = 1 program, over half our trainees go on to provide clinical services in forensic hospitals or correctional facilities. Some even administrate those services. I'm glad the ACGME requires that forensic fellows have correctional experience, because then when they testify or do presentence evaluations they know exactly what and where they are recommending for the defendant.

@Psychology ScientistLoad of BS. I am sure you would have changed your tune if the patient was a 6'2 200# man and you were a female.I am assuming you are male, obviously you are not going to be all that scared of an (unarmed) woman. Even if you are also a woman, it's still a relatively even match.

Most nurses are female, many are older. many violent patients are males, and many are young. Not the same situation.

If I was a peds nurse I would not be scared of a 10 year old throwing a tantrum, either. I would just pick him up and put him in a quiet room, lol.

if I was a psych nurse, would i be scared of the 6ft guy on a bad trip who thinks the devil is out to get him and happens to think I am a manifestation of that? Yea, I would be.

Arguing against sedating and using all necessary (human e) measures against violent psychotic patients is ridiculous, and shows a wanton disregard for the safety of psychiatric staff. Fact, no one is going to take care of these patients if we allow staff to be hurt while trying to help.

First to ClinkShrink, my issue is with forensic colleagues mudding the waters with providing false validation of treating basic antisocial behaviors and then often literally dumping these people on outpatient staff to be burdened, if not overtly threatened, to have to provide services to those NOT amenable to care.

To Itsthewoo, what is this MTE after my alias? And while there are some docs who aren't in the room when the patient escalates, I have been often and don't take others' safety for granted. So don't include me in that generalization. Frankly, I have little respect for Forensic Psychiatry these days. It is a whore subspecialty until proven otherwise, as it is doing what is financially convenient for the MD and just making general psychiatrists pick up the messes.

Alan Frances said it right at the end of his Antisocial Personality vignette in the DSM 4TR Case Studies Guide: if this sounds pessimistic, it was meant to be, regarding the lack of intervention offered with this disorder.

to the anonymous comment following my last comment, which I see has created a separate post per the "whore" statement, it is what it is. Forensic docs create this alleged diagnosis of some axis 1 disorder for some, and note that word, "some" patients who are just antisocial if not sociopaths, and when they, patients, leave correctional facilities, ride this fake train as far as they can.

I know because I have several overt examples in the community mental health clinic I work now, and these patients are at times terrorizing the staff. Again, I point to what Dr Frances wrote about 17 years ago in his vignette piece about antisocial personality disorder, the pessimism in trying to treat these people is justified.

The needs of the many outweigh the needs of the few. Sorry, if antisocial people want to genuinely change their ways for the better and come into treatment spontaneously and graciously, then good for them. That ain't happenin' too often, folks!!!

Anon Clinician, I understand what you're saying about antisocial people being given an axis I diagnosis, but what I don't understand is what motivates these folks to show up to see a psychiatrist? What do they get out of it? Are they trying to see if they can score some drug they're interested in? Or is it a condition of their release that they continue with outpatient treatment? I just don't understand what would motivate someone who believes nothing is wrong, to sit down and talk with a psychiatrist. I would have thought they would be more interested in wreaking havoc elsewhere.

anonclinI am late to this conversation, but I have to say that you have a vivid imagination when you say that forensic psychiatry is a "whore sub specialty"--I can't imagine any sane or insane whore wanting to work that hard with that population of patients for that low amount of pay. The US has a basic public health problem of a lack of psychiatric/mental health and substance abuse treatment infrastructure, but we have had a booming incarceration and prison building business for 30 years. Stigmatizing the practitioners working with the stimgatized patients...mmm...where have I felt that before....

Anti-social people love drama. They will wreak havok wherever they can. An incarcerated person with that type of personality, would be filling a need, that satisfies him, and him only. It has nothing to do with treatment. If that need, call it narcissistic supply, boredom, or a desire to understand how to better manipulate shrinks, whatever, disappears, so does their interest in treatment.

But if you lend them and an ear, and react positively to to their self-absorbed insights, they have a myriad of reasons for wanting interactions with a psychiatrist.

They also love mental patients. Which is why I study them. This always happens! I lose track of my thoughts, reply to a comment, and forget the main point of the original article.

I have been an RN for 14 years, 10 of them in psych. I am doing a contract in a correctional setting- where I do feel safer from physical harm than in other settings. I have always taken every precaution possible to avoid injury by a violent patient, and so far, for the most part, I have succeeded. Most of the previous decade I've spent practicing on inpatient units of every size and variety. The rest has been spent in clinics.The decision to press charges is difficult- and it isn't just the clinician who decides. While in a lot of places they ultimately are the ones who decide whether to go forward with charges, they are usually "encouraged" to drop charges. The hospitals don't back the nursing staff up as a general rule. I was part of a conversation this week and was shocked to hear that 2 different colleagues not only were surprised that we were allowed to press charges, but that several more seemed to think that we have no right to defend ourselves if necessary, to avoid injury. I can un-apologetically state that if I were attacked by ANYONE I would fight for my life. That doesn't mean injure someone when it can be avoided, but I'd rather be alive and have to defend my license than too dead to have any say.There are so many things one can do to protect themselves (sitting close to the door for example), but they don't always work. I have had to make the decision before, and it really depends on the situation, as stated by several people above. The first person to go after me in a psych setting was psychotic and very paranoid. It was a young African American woman, and she truly thought that we intended to lynch her. She fought valiently for what she thought was her own safety. Her actions were due to her illness, and I don't blame her one bit. I don't think it makes sense to file charges in cases like this- it's the responsibility of the people in charge and everyone employed there to do the best they can to back each other up and make sure that the proper security measures are in place. It happens.The other time I was assaulted by a patient and had reason to think I could be injured was when a man at a detox put me in a headlock. He wanted his first dose of methadone, which I declined because he was still high on the oxycontin he'd snorted on the way in. I stomped on his foot, and he let go. The decision was made for me- there was a police officer in the area who charged the man with a probation violation, making it a non issue for me.There will always be sick people who cannot help it. And, there will always be people that think they can get away with this, because it is tolerated way too often. It comes down to working in a place where you feel as if you can get help if needed, and where safety is priority. De escalation solves this problem most of the time, but in my 2 cases, it wouldn't have done much. Incidentally, I spent my nursing school years as a CNA in long term care and I got hit, kicked and spit on more times there than any psych setting. We are expected to take it. I won't. I am not a human punching bag, and wish my coworkers didn't feel as if they were.Also, it's hard to read the booking sheets of some of the guys I take care of at the jail, see the past convictions for violent crimes, and not be a little taken aback. I have cared for them in hospital setting, where we were not told of their past histories of violence. I am careful with everyone, and now appreciate the need for caution even more, after finding out who I had been caring for in the past.Blaming the person attacked is such a part of nursing culture that it's almost expected... And we are expected to take it because "it comes with the territory."

Happy: Thanks for your comment. Yes, the decision to charge assaultive patients is a tough one and seems to require the victims and the institutions to parse out multiple motivations. You made a good point about not knowing who you were treating; sometimes treatment teams themselves don't know the legal history or full history of violence of people who come into the unit. Some facilities forbid staff from doing online checks of public access legal history. And some patients seek treatment under an alias that also undermines a full history.

As a patient who once got very violent I always feel the need to apologise to medical ppl. I still fear that I may loose control again one day. It's scary. I remember every second of it but I wish I could forget. I didn't intend to hurt anyone, I didn't even remotely think that that would happen I just literally had no control over what I did. I was a 50kg 21 year old girl, tiny by some standards probably. I have bipolar disorder. I don't take any drugs, wasn't drunk or anything, just manic as hell. That was in the early days when we haven't figured out the right cocktail of meds for me. The police picked me up (nothing criminal, just outrageous behaviour) and took me to emergency where they put me into a small room and left me there for ages... when obviously I had a million other better things to do. There wasn't much space to pace around, I fiddled with everything in the room. The nurses kept coming all the time to take your blood pressure/temperature all the time and that irritated me as I had the police put me in handcuffs before that and I really didn't want to be handled so I just told them to keep their distance. The hours ticked by and those bright lights started to really irritate me because everything was white and bright. So I switched them off. A male nurse came and rather roughly twisted my hands behind my back and dragged me a short distance to a padded room. That was sort of sensory deprivation experience and it had just the opposite effect than what they were trying to achieve I suppose. There was nothing to keep me occupied, not enough space to even pace. When the next person checked up on me through the glass piece on the door I thought they were mocking me and I blew up and went nuts. I trashed the room (as much as you can trash a padded room), the bed, smashed my head against the door, arms, legs went everywhere and the screams that came out of my mouth... It took 8 people and quite a lot of sedative to put me out and that is by far the most humiliating experience I ever had... not because of what the medical staff did to me (trust me, it's not nice to be pinned down) but because I realised of what I'm capable of doing. The aggression wasn't directed at anyone, it just happened but I could have easily gouged someone's eye out.

I'm a nerdy computer scientist with a postgrad degree otherwise. So please, when dealing with agitated patients, keep in mind that not all of us are aggressive druggies who are out to hurt you and I'm sure you can detect some profound fear in the eyes of such mental ppl. And maybe, just maybe... some timely antipsychotic and valium could prevent such situations. I couldn't look at the faces of the ppl involved in the incident once they stabilised me, far too much shame